A STUDY TO FIND OUT THE EFFICACY OF CORTICAL MASTOIDECTOMY WITH
MYRINGOPLASTY IN CHRONIC SUPPURATIVE OTITIS MEDIA
Dissertation submitted to
THE TAMIL NADU DR.M.G.R. MEDICAL UNIVERSITY In partial fulfillment of the regulations
For the award of the degree of M.S., (Oto-Rhino-Laryngology)
Branch – IV
Department of ENT Kilpauk Medical College,
Chennai -10.
THE TAMIL NADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI
April 2013
CERTIFICATE
This is to certify that Dr. LEKSHMY R KURUP postgraduate student (2010-2013) in the department of Otorhinolaryngology,Govt. Kilpauk Medical College, Chennai, has done this dissertation titled “ A STUDY TO FIND OUT THE EFFICACY OF CORTICAL MASTOIDECTOMY WITH MYRINGOPLASTY IN CHRONIC SUPPURATIVE OTITIS MEDIA” under the direct guidance and supervision in partial fulfillment of the regulations laid down by the Tamil Nadu Dr. M.G.R. Medical University, Chennai, for M.S., Branch – IV Otorhinolaryngology Degree Examination.
Prof.. K. Ravi M.S., DLO., DNB Prof.G.Sankaranarayanan M.S.,DLO., DNB
Professor of ENT, Professor & HOD, Dept of ENT
Govt. Kilpauk Medical College. Govt. Kilpauk Medical College.
Chennai-600010. Chennai-600010.
Dr. P. RamakrishnanM.D., DLO.,
Dean
Govt. Kilpauk Medical College
Chennai-600010.
DECLARATION
I Dr. LEKSHMY R KURUP solemnly declare that the dissertation titled “A STUDY TO FIND OUT THE EFFICACY OF CORTICAL MASTOIDECTOMY WITH MYRINGOPLASTY IN CHRONIC SUPPURATIVE OTITIS MEDIA” is a bonafide work done by me at Govt.Kilpauk Medical College and Hospital under the guidance and supervision of
Prof. K. Ravi M.S., DLO., DNB
Professor of ENT
This dissertation is submitted to the Tamil Nadu Dr. M.G.R. Medical University towards the partial fulfillment of the requirements of M.S., Branch – IV Otorhinolaryngology Degree Examination.
Chennai Dr. Lekshmy R Kurup
Date :
ACKNOWLEDGEMENT
I express my profound gratitude to Dr P. Ramakrishnan M.D., DLO.,
the Dean of Govt. Kilpauk Medical College and Hospital, Chennai – 600010 for permitting me to use all the resources needed for this dissertation work.
I was fortunate enough to work under my guide Prof. K. Ravi M.S.,
DLO., DNB Professor of ENT, Department of Otorhinolaryngology without whose help I would not have successfully completed this dissertation work.
I am deeply indebted to my respected Head Of Department, Prof. G. Sankaranarayanan M.S.,DLO., DNB who has been my continuous
inspiration all through out the course of my study.
I record my heartfelt gratitude to all my beloved Assistant Professors, Dr. Ranjana Kumari, Dr. V. Prithviraj, Dr. (Major) J. Nirmal Kumar, Dr. K. Sanjay Kumar and Dr. K.M. Elango for the valuable suggestions and support in completing this work.
Last but not the least, I would like to thank our patients who rendered this study possible.
CONTENTS
Page No
Introduction 1
Aims of study 25
Review of Literature 26
Materials and Methods 42
Observations 48
Discussion 65
Conclusion 78
Proforma
Master Chart
Bibliography
INTRODUCTION
WHO (World Health Organization) defines chronic suppurative otitis media as a stage in ear disease in which there is a chronic infection of the middle ear cleft in the presence of persistent tympanic membrane perforation[1]. Chronic suppurative otitis media is typically a persistent disease, insidious in onset, often capable of causing severe destruction and irreversible sequelae and clinically manifests with deafness and discharge. According to Mawson’s textbook of Ear disease, it is persistent otorrhea through a non-intact tympanic membrane[3]
The global burden of chronic suppurative otitis media is estimated around 65-330 million of which 60% suffer from significant hearing impairment. It accounts for 28,000 deaths and a disease burden of more than 2 million DALYs. Incidence of CSOM is higher in developing countries because of poor socio-economic standards, poor nutrition and lack of health education. It affects both sexes and all age groups. In India, the overall prevalence rate is 46 and 16 persons per thousand in rural and urban population respectively. It is also the single most important cause of hearing impairment in rural population.
A mastoid is considered to be inflammatory when purulent exudates, granulation tissue, polypoid mucosa, cholesterol granuloma or
cholesteatoma are noted. It is mandatory that this diseased mastoid be cleared off the disease before undertaking any reconstruction.
Otologists have long realized the importance of mastoid disease in determining the success of tympanic membrane reconstruction. It is beyond doubt that the extension of pathologic process into mastoid air cell system requires exposure and removal. It is often possible to eliminate chronic progressive inflammation of the middle ear and mastoid, and at the same time have a reasonable chance to preserve residual hearing or preferably to improve hearing. Controversy has been centered on the best surgical technique to achieve this desirable result.
It is well known that chronic suppurative otitis media is a poor man’s disease. Poor living conditions, overcrowding, poor nutrition and hygiene have been suggested as a basis for widespread prevalence of this disease in third world countries.
Surgery plays an important role in its management and the outcome measures are closure of tympanic membrane perforation in myringoplasty, eradication of disease and achievement of a dry and safe ear in mastoidectomy and in some cases, improvement of hearing where ossicular reconstruction or ossiculoplasty is also carried out. A mastoidectomy done along with tympanoplasty may ensure clearance of
disease, saves time, money, unnecessary hospital stay, and repeated hospital visits for the patient.
ANATOMICAL CONSIDERATIONS OF MIDDLE EAR CLEFT:
For the purpose of description middle ear can be considered as a 6- sided cube.
Lateral wall: It is formed partly by bone forming the outer wall of epitympanum and hypotympanum respectively and mainly by the Tympanic membrane, which separates the external ear from middle ear.
It is convex towards the middle ear, the area of maximum convexity being called as umbo. Tympanic membrane is divided into two parts - the pars flaccida or shrapnel’s membrane above and pars tensa below by the anterior and posterior malleolar folds. The handle of malleus is attached to the pars tensa. In the upper part of pars tensa, the short process of malleus is seen. The Politzer's cone of light extends anteroinferiorly from the umbo.
Pars tensa is classically described as having 3 layers - an outer layer of squamous epithelium continuous with skin of external auditory meatus, a middle layer of fibrous tissue consisting of radial and circular fibers and an inner layer of mucosa of middle ear.
In 1851 Toyenbee demonstrated five layers for the tympanic membrane viz. the outermost epidermis of stratified squamous epithelium, a thin dermis of fibrous tissue, an outer radiate fibrous layer, an inner circular fibrous layer and an innermost thin mucous layer. The tympanic membrane is supplied by the Alderman's nerve (auricular branch of vagus or Arnold's nerve) in the posterior half, the auricular branch of auriculotemporal nerve in the anterior half and by the Jacobson's nerve (tympanic branch of glossopharyngeal nerve) on the medial surface.
Three holes present in the bone of medial surface of the lateral wall of tympanic cavity are the opening of the posterior canaliculus for entry of chorda tympani nerve at the junction of posterior and lateral walls of tympanum. The Glasserian fissure (petrotympanic fissure) which transmits the anterior tympanic branch of maxillary artery and the canalicus (canal of Huguier) on the medial aspect of the fissure for the exit of chorda tympani nerve.
The circumference of tympanic membrane is thickened forming the fibro cartilaginous annulus, which is fixed into tympanic sulcus except superiorly at the notch of Rivinus. Annulus is continuous with the anterior and posterior malleolar fold thus making it possible to consider
attic perforations as marginal. The roof of tympanum is formed by Tegmen, which separates it from dura of middle cranial fossa.
Floor: It is narrow and formed of a thin plate of bone, which separates tympanum from the dome of jugular bulb. At the junction of floor and medial wall there is a small opening, which transmits the Jacobson's nerve.
Anterior wall: It is also narrow and formed of a thin plate of bone, which separates tympanum from internal carotid artery. It is perforated by the carotico tympanic nerves and tympanic branches of internal carotid artery. It has two openings - the lower one leading to bony part of eustachian tube and upper one transmitting tendon of tensor tympani.
Posterior wall: It has in its upper part, the aditus - ad – antrum opening into the mastoid antrum. Below aditus is a small depression - the fossa incudis lodging the short process of incus and its ligament. Below this fossa is the pyramid, which contains the stapedius muscle. The facial recess is a shallow space bounded medially by the descending part of facial nerve and laterally by the tympanic annulus. The sinus tympani is another deep gutter starting above at the oval window niche, medial to descending part of facial nerve and to the pyramid and passes behind the round window niche to hypotympanum. In intact canal wall
mastoidectomy this sinus is frequently missed leading to residual cholesteatoma.
Medial wall: Of all the walls, this is the most important and is marked by the promontory produced by the basal turn of cochlea. Behind and above is the fenestra vestibuli, which is reniform in shape and closed by the stapes footplate and its annular ligament. The fenestra cochlea lies behind and below the promontory and is closed by the secondary tympanic membrane. The processes cochleariformis is a projection anteriorly around which hooks the tendon of tensor tympani and it also denotes the start of the horizontal portion of facial nerve. There is a posterior extension of the promontory above the round window niche called as subiculum and another one below oval window niche called as ponticulus. The horizontal part of facial nerve runs from processes cochleariformisupto its second genu at the fossa incudis, above the promontory and oval window niche. The bony fallopian canal is deficient here in 10% of individuals and the nerve may overlie the oval window niche. The cavity of the middle ear is divided into:
• Mesotympanum which lies medial to the tympanic membrane
• Epitympanum or attic, lying above the level of the horizontal portion of facial nerve, medial to the horizontal part of squama (outer attic wall)
• Hypotympanum lying below the tympanic sulcus.
Contents of the middle ear cavity includes (i) air, (ii) ossicles - malleus, incus and stapes, (iii) intra-tympanic muscles - tensor tympani and stapedius, (iv) tympanic plexus of nerves, (v) chorda tympani nerve and (vi) the arteries and veins.
The pneumatic air cell system arises in conjunction with the enlarging temporal bone as an outgrowth of middle ear and antrum. From the antrum, the cellular system extends into adjacent bone and is grouped as follows:
• Periantral cells
• Tipcells – superficial and deep, separated by the digastric ridge
• Peri-sinuscells
• Peri-labyrinthine cells – supra, infra and retrolabyrinthine
• Retrofacial cells
• Petrosal cells
• Hypotympanic cells
• Zygomatic cells
The extent of pneumatisation varies between individuals. In 20% of the total population mastoid air cells are totally absent - the bone being primarily sclerotic. The anatomic configuration created surgically consists of exposing, but not injuring, the important structures bordering the mastoid cavity. The posterior limit of the mastoid cavity is formed by the bone overlying the posterior dura. The major landmark is the large convex channel running from the superolateral corner to the postero- medial corner, formed by the lateral sinus.
The superior limit of this wall forms an acute angle with the tegmen, the sinodural angle. The tegmen forms the upper wall of the cavity.
Inferiorly the mastoid tip forms the wall superficially with the concave digastric ridge projecting into the space medial to the tip. The cavity is limited anteriorly by the posterior wall of the external auditory canal and the vertical segment of the facial nerve lying at the base of this wall.
This portion of the facial nerve extends from the fossa incudis to the anterior end of digastric ridge. On the medial wall of mastoid cavity the lateral and posterior semicircular canals occupy the major portion. The triangle between the external prominence of these canals and the posterosuperior corner of the mastoid is known as Trautmann's triangle from which a group of antral cells invades the petrous deeply, to the region of internal auditory canal. Visualisation of the medial wall may be
confused by the presence of Korner's septum, which divides the cells into superficial and deep regions. The antrum lies approximately 15 mm deep to the Mac Even’s triangle in an adult.
FUNCTIONS OF MIDDLE EAR (PHYSIOLOGICAL CONSIDERATIONS OF MIDDLE EAR)
The tympanic membrane and ossicles not only conduct the sound but also increases the sound pressure before it is transmitted to cochlea.
The increase in sound pressure provided by tympanic membrane and ossicles is necessary to overcome the impedance (resistance} to the sound transmission and is called impedance matching of the ear.
Von Bekesy, by measuring the amplitude of motion of different portions of tympanic membrane in response to a constant stimulus, found that at all frequencies upto 2400 cycles per second (CPS) the whole central conical portion of the do and handle of malleus moves as a unit about an axis of rotation passing through the anterior and lateral process.
The amplitude is greatest near the inferior edge of the membrane. Above 2400 CPS, the membrane no longer vibrates as a stiff cone but in segments with the manubrium lagging behind the adjacent portions of the membrane.
Malleus and incus vibrate as combined unit rocking on a linear axis, which runs from the anterior ligament of malleus to short process of the incus. With sounds of moderate intensity, the anterior end of foot plate of stapes –oscillates with greater amplitude than posterior end. This is because fibres of annular ligament are larger at the anterior end than at the posterior end. With high sound levels the mode of action changes and a side to side rocking movement about an axis running longitudinally through the length of foot plate is seen. Here the volume displacement of inner ear fluids is proportionately less and this modification is by stapedial reflex and so the inner ear is protected (John Groves 1979).
THE TRANSFORMER ACTION OF MIDDLE EAR/MIDDLE EAR IMPEDENCE MATCHING:
Sound waves do not pass readily from one medium to another of different acoustical resistance. Between air with an acoustical resistance of only 41.5 mechanical Obms/cm2 and seawater with a resistance of 61000, the impedance mismatching is very great. Only 0.1% of energy of sound would be transmitted representing a loss of 30 db to overcome this an acoustic lever system is formed by drum and ossicles. The aerial ratio between tympanic membrane and oval window - called as the Hydraulic ratio is 14:1. A mechanical advantage of approximately 1.3 is available
since handle of malleus is longer than long process of incus. This is called ossicular chain lever ratio. The result of the two gains in the hydraulic ratio and ossicular chain lever ratio is 18.3. By definition the impedance transformation ratio is square of this figure i.e. 336. The ratio of acoustic impedance of air and water is 3880.So impedance matching due to middle ear, although very substantial, is less than ideally required (Hawkins J E 1966)
An additional virtue of middle ear mechanism is that it provides preferential conduction of sound to oval window.
HISTORY:
Chronic suppurative otitis media is a persistent disease, insidious in onset, often capable of causing severe destruction and irreversible sequelae and clinically manifests with deafness and discharges.
The management of chronic suppurative otitis media has witnessed a profound change over the last 100 years from the early attempts at surgical exposure of the middle ear in 1889 to the present day techniques of tympanoplasty in persistent but inactive disease and the canal-wall up or the canal-wall-down techniques in cholesteatoma surgery.
The choice of operative treatment in uncomplicated suppurative disease of ear depends to a large extend on the experience of the operator,
the extent of the disease,the preoperative hearing and whether or not the patient can be followed up post-operatively.
Though the mastoid surgery and middle ear reconstruction has progressed to such a great extend, there are group of patients in whom it is advisable not to undertake such detailed procedures because of the difficulty in postoperative care of the mastoid cavity. This includes patients with absent auditory function and patients with severe mental retardation. Here total obliterations of mastoid, middle ear and external meatus has been suggested (Rambo 1958, Gacek 1979 and Schuknechdt 1984).
Shambaugh in his textbook ‘Surgery of the Ear’ states that the first contemplation of surgery for mastoid infection, occurred four centuries ago. According to him the first recorded successful mastoid operation was done by Jean Petit of Paris and shortly thereafter in 1776, a Prussian surgeon, who operated on a soldier with a draining ear.
The first well described technique for dealing with acute mastoiditis were set forth by William Wilde in 1853. Wilde’s name is still remembered in connection with the post-aural incision. It was Herman Schwartze who outlined clearly the indication for simple mastoidectomy. The radical mastoid operation was devised by Emmanual Zaufel and popularized by William Stacke. The procedure
was used for chronic suppuration of the ear and in cases of cholesteatoma.
DEFINITIONS:
Myringoplasty is an operation in which the reconstructive procedure is limited to the repair of a tympanic membrane perforation (Ballenger 1985). In 1878, Berthold successfully closed a perforation with full thickness skin and introduced the term “Myringoplastik” (Gibb et al 1982).
The term, Tympanoplasty was coined by Fritz Zollner and Horse Wullstein. Zollner in 1951 andWullstein in 1952 began to set of similar operations to provide sound protection of round window and to reconstruct sound pressure transformation for the oval window (zollner F 1955; Zollner F 1963; Wullstein H 1960). The two basic principles of tympanoplasty had been defined, namely, sound pressure transformation of the oval window and sound protection for the round window (Shambaugh 1980).According to Sheehy (1973) the goals of tympanoplasty are two viz. elimination of disease and permanent restoration of hearing.
The work of Zollner and Wullstein found light in 1921, whenNylen introduced a mono ocular operating microscope. One year after that Holmgren introduced ocular loop. This was an important advance destined to play an increasing role in the perfection of tympanoplastic surgery. In 1953, the Zeiss operating microscope became available and during the same year Wullstein and Zollner launched the tympanoplasty methods, in the 5th international congress of Otorhinolaryngology in Amsterdam.
According to the Committee on conservation of hearing, of the American Academy of Ophthalmology and Otolaryngology 1965, Tympanoplasty can be defined as an operation performed to eradicate disease in the middle ear and to reconstruct the hearing mechanism, with or without tympanic membrane grafting (Frootko N J 1987)[24].
Ossiculoplasty can be defined as an operation performed to repair or reconstruct the ossicular chain (Nicholas J F 1987).
Cortical Mastoidectomyis defined as a surgical procedure in which all accessible mastoid air cells are removed, posterior canal thinned and aditus made patent. Can be broadly divided into open or canal-wall-down procedures and closed or canal wall-up procedures.
Tympanoplasty is an operation performed to eradicate disease in the middle ear and to reconstruct the hearing mechanism with or without tympanic membrane grafting.
Types of Tympanoplasty[2]
Wullstein has classified the more commonly encountered abnormal patterns of sound transmission into five types:
Type I: defines a normal middle ear with an intact mobile ossicular chain. Myringoplasty is often incorrectly referred to as type I tympanoplasty because myringoplasty does not imply removal of disease from the middle ear (Nicholas 1987)
Type II: Here, after clearance of disease sound transmission is through a deformed but functioning ossicular chain when it is called Type II (a).
Any mechanism which joins the tympanic membrane with stapes foot plate which retains a lever advantage is also included in Type II. If this is a malleus stapes assembly, it is called Type II (b) and if it is a new construction independent of malleus it is called type II (c).
Type III: Is otherwise known as columella effect, where sound is transmitted directly through a mobile stapes. Membrane perforation with erosion of malleus and incus with presence of intact and mobile stapes.
(Columella tympanoplasty or Myringo-stapediopexy)
Type IV: Is otherwise known as ‘baffle effect’. Here the mobile foot plate over the oval window is left exposed. A small cavity is created called ‘Kleinepauke’ – as the Germans put it – in continuity with the Eustachian tube which provides sound protection for the round window.
Type V: Is fenestration operation done in a case with fixed stapes. Here sound enters the labyrinth by a fistula of lateral semicircular canal.
Type VI:In addition to all these Gercia Ibanez in 1961 described sonoinversion where round window is left exposed to direct impact of sound wave and the mobile stapes footplate is protected by a small tympanic air space in continuity with Eustachian tube.
Of all these techniques Type IV & type V as well as sono-inversion are seldom performed today. Type I & II has evolved under the modern techniques of tympanoplasty and ossiculoplasty to a very great extent.
However, the columella effect is still a most useful procedure, especially in the hands of the less expert and is said to give a socially acceptable hearing, a little above the 25 dB level for the speech frequencies. (Beales H P 1978)[20].
FUNCTIONS OF MASTOID AIR CELL SYSTEM:
It serves as an air reservoir for middle ear and also provides resonance to the sound. Further it acts as an insulating chamber for protecting the labyrinth from temperature variations.
ANATOMY & PATHOLOGY OF MUCOUS LINING OF MIDDLE EAR CLEFT:
The Eustachian tube and anterior half of middle ear space are lined by pseudo stratified columnar ciliated epithelium and as the lining proceeds posteriorly it gradually merges to a single layer of cuboidal epithelium. Further as it extends into mastoid antrum and air cells it becomes flat pavement epithelium. Developmentally the level of chorda tympani nerve can be considered as the borderline between the
respiratory epithelium and pavement epithelium. In the respiratory part there are a large number of goblet cells, which secretes mucous actively if irritated by infection, allergy or negative pressure. This mucous is secon- darily infected and results finally in denudation of epithelial lining- The tissue then reacts by oedema or production of granulation tissue. Infection can reach middle ear cleft via eustachian tube or an already existing perforation or by way of a retraction pocket of the tympanic membrane which gives way.
MICROBIOLOGY OF CSOM
TUBO TYMPANIC DISEASE :
The commonest organisms found isolated are Pseudomonas aeruginosa, Proteus species and Staphylococcus aureus . Other organisms found less commonly are E.coli, Streptococcus pneumoniae, Diptheroids, Klebsiella sps and the Bacteroides21.
The histopathological changes seen in chronic suppurative otitis media vary with the degree and the extent of disease. The degree of inflammation seen is related to clinical activity, with the most intense changes seen in ears with continuous otorrhoea. The changes occurring are:
A chronic inflammatory infiltrate consisting of lymphocytes, plasma cells and histiocytes develops. Associated with this is increased capillary permeability of laminar propria of the middle ear mucosa, with mucosal edema.
The middle year epithelium undergoes transformation to resemble respiratory epithelium found in other sites. This consists of an increase in the number of goblet cells and ciliated cells. In addition the epithelium becomes glandular. This charge in character of the epithelium may take place in the mastoid air cells as well as in the middle ear cavity. The secretion from newly formed glands is an important part of the discharge seen in chronic suppurative otitis media.
An inflammatory granulation tissue develops during the early stages of healing after destruction of tissue. In some cases florid granulation tissue results in the gross appearances of an aural polyp.
The late stages of disease are characterized by a decrease in vascularity and fibrosis. These changes are particularly well seen in mastoid air cells, in which sclerosis and new bone formation occur.
CLINICAL PRESENTATION
SYMPTOMS:
Aural discharge:
The discharge can be continuous or intermittent, tends to be profuse, and is frequently mucoid and very rarely purulent. The increase in amount of discharge can be precipitated by upper respiratory tract infections or by entry of water. Blood stained discharge indicates florid granulation tissue and aural polyp. Persistent otorrhoea unresponsive to medical treatment indicate a so called ‘Mastoid reservoir of disease with inflammation throughout the middle ear cleft.
Hearing loss :
The predominant deafness is conductive in nature.
Factors that influence the degree of deafness are:
• Size and position of Tympanic membrane defect.
• Large perforations will reduce the efficiency of TM to greater degree. Posterior perforations exposing the posterior mesotympanum produce a more severe deafness owing to reduction of the ‘baffle effect’ on the round window. Small anterior defects often produce nearly no deafness.
• Presence of middle ear pathology such as edema and granulation tissue influence the sound conducting mechanism. The sensorineural deafness in chronically discharging ears is due to passage of bacterial toxins across the round window membrane to the cochlea and the loss is mainly in the high frequencies
CLINICAL MANAGEMENT:
DIAGNOSTIC STEPS:
1. Accurate documentation of the tympanic membrane defect:
This is achieved by examination on table with Microscope 2. Culture sensitivity of the discharge is done for proper antibiotics.
3. Assessment of hearing loss:
This is done by standard Rinne, Weber tuning fork tests. Pure tone audiometry with air and bone conduction threshold estimation should be performed. Adequate masking is essential, particularly in patients with bilateral conductive or mixed hearing loss. Speech audiometry is often helpful and is required for any patient in whom surgical reconstruction is being considered .
Lateral Oblique Radiograph of Skull for Mastoids (LAW’S VIEW) Provide useful information on mastoid cellularity and the position of the sigmoid sinus and tegmen.
4. CT Scan of Nose and Paranasal Sinuses
This is done to rule out any focus of sepsis in the nose and paranasal sinuses.It is done following a diagnostic nasal endoscopy examination. If any pathology found it is cleared off before undertaking ear surgery.
5. Pure Tone Audiometry MEDICAL TREATMENT :
The aims of Medical treatment in these cases is to eliminate infection and hence otorrhoea. The correction of hearing loss and re- establishment of an intact tympanic membrane may require a surgical procedure.
The removal of discharge from an ear with active CSOM is an essential prerequisite for successful treatment. This is done by suction, dry mopping or wet irrigation.
Topical agents used in the treatment of CSOM are a combination of antibiotics, antifungals, antiseptics, solvents and steroids. The systemic antibiotics like parenteral penicillin’s, cephalosporins and
aminoglycosides and oral preparations like ciprofloxacin are effective in the treatment of CSOM.
FAILURE OF MEDICAL TREATMENT:
• Poor drainage of inflammatory exudates from the middle ear particularly with a pinhole perforation or discharging ventilation tube.
• Persistence of osteitis with mastoid granulations.
• Microbiological factors-Virulent and resistant organisms may be responsible for failure of treatment.
• Repeated re-infection via the Eustachian tube. This is due to chronic infection in the nasopharynx, adenoids, palatine tonsils or sinuses.
SURGICAL TREATMENT:
The indications for surgical intervention in chronic ear disease are basically two fold the control of infection and the restoration of function.
Since hearing improvement is not usually possible unless the disease is eliminated from the involved ear, this remains a primary consideration in surgery. With the present-day techniques, an equal consideration is given to the hearing improvement.
GRAFTS USED IN TYMPANOPLASTY AND MASTOIDECTOMY Terminology (FROOTKO, 1985):
Four types of Grafts can be defined according to the genetic relationship between the donor and the host:
Autograft: Tissue transplanted from one part of the body to another in the same individual.
Isograft: Tissue transplanted between genetically identical individuals.
Allograft (Homograft): Tissue transplanted between genetically non- identical members of the same species.
Xenograft: Tissue transplanted between members of different species.
AIMS AND OBJECTIVES OF THE STUDY
1.To determine the efficacy of myringoplasty combined with cortical mastoidectomy with respect to takeup of graft in chronic suppurative otitis media with persistent mucosal disease.
2. To determine the efficacy of myringoplasty combined with cortical mastoidectomy with respect to post operative audiological improvement in chronic suppurative otitis media with persistent mucosal disease.
REVIEW OF LITERATURE
Hippocrates, “Father of Medicine” had noticed the development of intracranial complications following ear discharge, the treatment for such a disease was not well established due to lack of better understanding of the disease and the non availability of better technology. Although, the introduction of sulpha drugs by Domegkin 1953 and penicillin by Sir Alexander Fleming in 1942 reduced the mortality in case of safe type of CSOM, they could not cure cholesteatoma.
Shambaugh [29] in his textbook ‘Surgery of the Ear’ states that the first contemplation of surgery for mastoid infection, occurred four centuries ago. According to him the first recorded successful mastoid operation was done by Jean Petit of Paris and shortly thereafter in 1776, a Prussian surgeon, who operated on a soldier with a draining ear.
1736 AD PETIT Described mastoid operation forMastoiditis
1873 AD SCHWARTZE23 Established the indication for and methods of Simple Mastoidectomy
1889 AD KUSTER AND STACKE
Introduced Radical Mastoidectomy.
1910 AD BONDY Modified Radical Mastoidectomy.
The above procedures were developed mostly to eliminate the disease from tympano mastoid area, to prevent the development of life threatening complications and to exteriorize the cavities for the purpose of inspection and cleaning of recurrent process for the rest of the patient’s life and if possible to achieve a dry ear, but functional hearing was not at all a major criterion.
1921 AD NYLEN Introduced monocular operating microscope in ear surgery.
1922 AD HOLMGREN Introduced Binocular operating Microscope.
These were the major developments in the field of mastoid surgery:
1951 AD ZOLLNER Used Autologous fascia lata in tympanoplasty. He is the first man to apply the principles of middle ear transformer to the surgical reconstruction.
1952 AD WULLSTEIN Introduced the term tympanoplasty. He launched tympanoplasty methods using free skin grafts and he introduced absorbable gelatin sponge.
The techniques introduced by them entirely changed the mastoidectomy results and functional results of hearing improvement were remarkable
1961 GUILFORD PALVA
Developed mastoid cavity obliteration techniques. These have minimized the postoperative large cavity problems.
1963 AD 1968 AD
JANSEN SHEEHY
Developed intact canal wall techniques to eliminate cavity problems. In this procedure, a normal looking external auditory canal with better hearing results can be achieved.
1991 AD HELLSTROM et al
Repaired small perforations of tympanic membrane by application of weak acids, Sodium hyaluronate.
1993 AD PREMCHANDRA
et al Used cultured epithelial keratinocytes to form a healthy, protective lining of open mastoid cavities.
During evolution of various surgical procedures many techniques were recommended of which some were discarded as better methods evolved in the management of chronic discharging ears.
Grafts used in Tympanoplasty&Mastoidectomy:
There are four different types of grafts now available like the autograft, isograft, homograft or allograft and heterograft (Frootko 1987)[29]. In 1640 a segment of bladder was used in an attempt to close tympanic membrane perforation by Marcus Banzer (Thawley 1982). In Ringenberg’s article (1978), he has mentioned that artificial drum was proposed by Leschevian in 1973 and, by Authenrinth and Bohneberger in 1815. In 1878 Berthold successfully closed a perforation with a full thickness skin graft (Gibb et al 1982). But in an article by Wullstein (1971) it is said that it is Heerman in 1960 who first used autograft temporalis fascia successfully and Wullstein first used absorbable gelatin sponge known as gel foam to promote growth of new health middle ear mucosa, to maintain a middle ear free of adhesions and to support the neotympanic membrane (Wullstein 1960). As an autograft, in the repair of tympanic membrane perforation, the temporalis fascia is now preferred because it has a low metabolic rate, easy availability and good survival prospects.
According to Ballenger (1977)[19] the connective tissue graft used to replace the missing fibrous element of drum is rapidly covered by proliferating squamous layer which quickly carries blood to the graft during which time it is able to survive by tissue perfusion. Calcattera
(1972) stated that, transplanted tissue with lower metabolic requirements such as connective tissue has been found to be much more resistant to necrosis in the early postoperative period. The use of fresh autograft connective tissue such as vein or fascia avoids complications of storage and offers greater degree of success (Ballenger, 1977)[19].
According to Shambaugh (1980) the fascial graft may be allowed to dry before use or even compressed in a special clamp. In the dry parchment like state, it is easily cut down to size and accurately applied in the tympanic membrane defect. Drying of the temporalis fascia does not seem to impair the viability of the fascia and it makes it easier to handle.
It is not advisable to dry temporalis fascia by heat, as is sometimes recommended, as the graft may be devitalized in parts leading to higher incidence of graft failure (Beales 1979)[20]
The temporalis fascia graft should not be allowed to dry but should be placed in a moist chamber if there is to be any delay in its use. The graft should not be handled with finger but should be manipulated with instruments free of fibres or lint particles (Hough 1970). It is Hough’s firm belief that procedures which deliberately damages the cell or alter the chemistry of graft should be discarded. It is illogical to compromise a good result by drying the tissue until it becomes parchment like, or conversely to place it in a non physiological solution.
A variety of connective tissue homologous graft materials are in use, which include fascia, dura, and homograft tympanic membrane with or without ossicles while autologous temporalis fascia also enjoys popular support. Smyth (1980) demonstrated no significant difference in success rate between autologous temporalis fascia and homologous dura when hearing results are compared after 6 months in patients with an intact ossicular chain. Walby et al (1982) observed the effects of surgical preparation of autologous temporalis fascia in tissue culture. Scraping loose connective tissue from the fascia or allowing it to dehydrate caused significant reduction in fibroblast growth in tissue culture while both procedures completely abolished it (Shenoi 1987).
Betow (1982)[21] is of opinion that, by using homografts in routine surgery of the middle ear, the structural and functional results are equivalent to those of autografts. We can use homograft fascia, perichondrium, dura, ossicles and cartilage in the same way as in autografts. He says that in cases of limited inflammation, the goals are easily fulfilled through the use of autografts. The most difficult problem however, remains in those cases in which a large part of the middle ear has been destroyed by infection, where the tympanic membrane and ossicles are missing or where a considerable part of the middle ear has to be removed because of extensive cholesteatoma. particularly after a
radical operation, it is impossible to reconstruct a good functional transmission system just by using an autograft.
It was Betow (1959) who attempted an enbloc homograft consisting of part of meatal skin, the tympanic membrane and the whole ossicular chain. Betow in this article gives an account of the evolution of homografts. In 1640, Marchius repaired an ear drum with a sheep’s bladder, which was stretched over a piece of ivory. In 1894, Politzer pointed to the possibilities of homograft bone transplantation in ear surgery.In 1957 Tobeck reported successful transplantation of a stapes after removal of the patients stapes in 7 cases of otosclerosis. In 1959 Portman and Ceresia mentioned the experimental implantation of chilled, conserved stapes as homografts. In 1960, Glaninger also gave an account of successful transplantation of the stapes. At the same time after experimental research by Pulec in cats, the possibility of transplanting a homograft incus for restoration of the ossicular chain was later accepted as routine by many surgeons. In 1964, Marquet began with transplantation of tympanic membrane only. In 1966, he reported the use of preserved cadaver tympanic membrane. In 1969, Brandow and Smyth and Kerr reported on tympanic membrane homografts. Regarding the preservation of the homografts Glasscock, House and Graham (1972) reported the preservation of enbloc allografts in 70% ethyl alcohol and
with this a graft take rate of 70%. Betow (1982) stored them in Cialit which is 2 – (ethyl-mercurymercaptol) benzoxazole – carbonic acid sodium. He cited the advantages of cialit as its low local toxicity, strong bacteriostatic and antimycotic effect. When transplants are taken from cadavers Betow excluded as donors patients died of infectious diseases such as hepatitis, or tuberculosis.
In order to stabilize the homografts Seelich, Marquest and Portman have found a combination of concentrated human fibrinogen and factor XIII with a thrombin calcium chloride aprotinin solution to be a good adhesive (Frooto J.N.1987)
Chiossone (19770 gives an account of the establishment of an ear bank which he says have proved to be insuring a regular supply of high quality homografts for the otologic surgeon (Chiossone E 1977)[22].
Rafto described the tympanic membrane as a spiderweb like structure and a part of organ of hearing.
Ambrose Pare in 16thcentury suggested surgery for mastoid infection in young king Charles of France,who was moribund with high fever and discharging ear. Berthold in 1878 did the first myringoplasty including removal of epithelium and grafting of skin.
Albert et al[3]conducted study on 40 patients out of which there were 27 males and 13 females. Out of all cases 33 patients had aditusblock,inspite of the fact that 8 cases were inactive during the study.
They found aerobic and anaerobic cultures from mastoid antral granulation tissue.Out of 40 cases 23 turned out positive for aerobic culture and 1 turned positive for anaerobic. Culture reports surprisingly showed that 6 out of 8 inactive ears were culture positive, and out of the 8 inactive group,5 ears were dry for more than one and half years, yet three of these grew aerobes of which two had two organisms each. The conclusion was –inspection of mastoid antrum ,in all cases of CSOM,irrespective of duration of disease should form an integral part of the surgery because of the mastoid granulations blocking aditus is not always sterile .
In study conducted by Ashok k saha[4] type I Tympanoplasty was done in 30 patients and cortical mastoidectomy with tympanoplasty was done in 10 patients(male -24 and female -16).Bilateral disease was seen in 30%.right ear disease was seen in 8 cases(20%) and left ear disease in 20 cases(50%).bilateral disease in 12 cases(30%). Right ear operated in 12 cases and left ear in 28cases.Youngest patient was 14 years and oldest was 56 years. Out of total 40 patients,30 patients underwent type I tympanoplasty alone whereas 10 patients with discharging year were
taken up for cortical mastoidectomy with type I tympanoplasty. Overall graft take-up was found to be 85%,in males it was 83.3% and females it was 87.55%.In this study they have concluded that, it is advisable to do cortical mastoidectomy with type I tympanoplasty especially in chronic persistent discharging years, to remove antral pathology if any.
Werhs etal[5] observed that it is necessary to maintain an aerated mastoid on the basis of the fact that poor Eustachian tube function is the most common cause of tympanoplastyfailures, though inadvertent block of ET orifice by graft material and middle ear adhesions also contributes.
Hedge etal[6] studied the relation between area of mastoid pneumatic system and period of disease. They stated that decreased pneumatisation of mastoid in patients with chronic ear disease is due to chronic inflammation,and not due to otitis media in infancy.Hence it is important to give a good aerating mastoidectomy to clear the disease process and aid in success of a good tympanoplasty.
Adkins, White and Charleston[7] followed up 71 cases of type I tympanoplasty for 18 months and observed the different factors influencing the success rate. The total success rate was 89%.The only factors which influenced the graft uptake in their study were the condition of the opposite ear at the time of surgery and the size of perforation. Out of the 8 cases that failed 7 patients had large to subtotal
perforations. Even though none of the contralateral ears had active disease at the time of operation, in adult population one of four and in pediatric population three of four failures occurred in bilateral chronic otitis media.
Jackler R K, Schindler RA[8] studied 82 patients who had chronic ear discharge,sclerosed mastoid and previous failed myringoplasty.Graft take-up was 86.6% and air-bone gap closure upto 20dB occurred in 85%.They concluded that mastoidectomy is an effective adjunct to simple tympanic membrane reconstruction alone.
In a study by Jackler K.R.(1984) Schindler RA[9]to determine whether mastoidectomy is an effective means of repneumatisisng the mastoid air cell system and eradicating mastoid source of infection, he came to a conclusion that pneumatic spaces within the mastoid represented an ‘air reservoir’ which can be drawn upon during periods of Eustachian tube dysfunction and buffer the middle ear against the development of detrimental negative pressures. Mastoid inflammatory disease if untreated, may result in recurrent suppuration and graft failure.
Small mastoid volume aside from its well known association with chronic suppurative otitis media has been shown to effect adversely graft survival following myringoplasty. According to him simple mastoidectomy is an
effective means of re-pneumatising the mastoid and eradicating mastoid source of infection.
Papers published by Scandinavian authors present a very discouraging picture of hearing improvement following tympanoplasty.
Surgery is viewed as a means of preserving hearing and not improving it (Leirle et al 1965).
Jackler (1984)[8,9] assessed the mastoid cavity from x-ray mastoids by noting the cross sectional area of mastoid pneumatisation, usingplanimetric method of Diamont (1940). He divided mastoids into 3 groups according to mastoid size.
1) Small 0 – 5 cm2 2) Medium 5 – 10 cm2 3) Large 7 – 10 cm2
Jackler noticed a trend of increasingly successful results of graft take-up with larger mastoid sizes. According to him substantial hearing improvement was achieved with mastoids of all sizes. The degree of closure of air-bone gap was, however, dependent upon mastoid size. In all three frequencies (500, 1000, 2000 Hz) mastoid of 5 cm2 fared better than those less than 5 cm2.
Similar studies had also been conducted by Holmquist[11] (1972) and he also compared his results with material published by Diamont[10]
(1940), healing after myringoplasty is better when mastoid is pneumatised.
Outcome of tympanoplasty with and without cortical mastoidectomy for tubotympanic chronic otitis media authored by Habib MA, Huq MZ , Aktaruzzaman M, Alam MS etal [12] did their study on sixty patients out of which half underwent type I tympanoplasty and group II underwent cortical mastoidectomy with type I tympanoplasty. They compared postoperative hearing outcome between the 2 groups.After tympanoplasty the mean air bone gap(ABG) closure was 9.33dB in group I and in group II it was 20.61dB.
Also it was observed that closure of ABG was greater in small to medium sized perforations in group I i.e. 10dB whereas it more in medium and large perforations in group II ie around 22dB.They concluded on the basis of their study that tympanoplasty when done with cortical mastoidectomy is the best treatment method for chronic otitis media. They stated that when tympanoplasty alone is done there is a chance of leaving behind granulation tissue in the middle ear cleft, hence compromising with the long term results.
Vartiainen E, Kansanen M[13] in their study on tympano mastoidectomy for chronic otitis media without cholesteatoma published in journal of otolaryngol Head and Neck surgery in 1992,106,page 230- 234 said that chronic otitis media even after medical treatment and made dry, some amount of dormant mastoiditis continues, which has every potential to become active again. Hence cortical mastoidectomy with tympanoplasty proves to be the best treatment modality for this disease.
An article on impact of mastoidectomy on simple tympanic membrane perforation repair authored by McGraw etal[15] published in Laryngoscope in 2004 volume 114, page 506-511 concluded that hearing improvement was more in the mastoidectomy group than tympanoplasty alone and also said that intact canal wall mastoidectomy improves long term outcome.
Ruhl C M etal[16]analyzed 135 patients who underwent revision mastoidectomy with tympanoplasty, using clinical and audiological data,with an eighteen months follow up. It was found that graft take-up rate for the whole group was 90.4%.It was concluded that an aerating mastoidectomy is indicated in those patients who have failed a prior tympanoplasty.
Nayak et al[17]studied the role of surgically created mastoid air reservoir in the success of tympanoplasty. The study consisted of two groups with 20 patients each and the follow up period was with mean 1.7years.The result at the end of six months was supporting the mastoidectomy group with 100% graft take-up versus 60% in myringoplasty group. Hence they concluded that a mastoidectomy is necessary even in a dry ear in order to create a mastoid air reservoir, which shall possibly compensate for the damaging effects of poor eustachian tube function.Also said that mastoidectomy when combined with myringoplasty has high success rate.
MATERIALS AND METHODS
STUDY DESIGN: Prospective study
STUDY PLACE: Department of ENT,KMC & GRH STUDY PERIOD: October 2010 to December 2012
FOLLOW UP PERIOD: November 2010 to December 2012 SAMPLE SIZE: 50 patients
INCLUSION CRITERIA:
1.Patients with chronic ear discharge( Chronic Suppurative Otitis Media,safe type) attending ENT OPD at KMC and GRH.
2. Age group 18 to 60 yrs of age.
3. Both gender.
5.Unilateral or bilateSral disease.
EXCLUSION CRITERIA:
1.Patients above the age of 60yrs or below 18 yrs.
2. Chronic Suppurative Otitis media- unsafe type.
3.Deblitated and Immunocompromised patients.
4.Pregnant and lactating women
Normal Tympanic Membrane
Central Perforation
5.Patients with external or middle ear abnormalities(congenital or acquired)
MATERIALS
In this study the procedure adopted is cortical mastoidectomy with myringoplasty for one set of patients(Group 1) and myringoplasty alone(Group 2) for another set.
The equipments used are 1. Binocular Microscope
2. Karl Storz zero degree Endoscope with camera and monitor.
3.Middle ear Microsurgical instruments like Rosens, Plester,curette,picketc.
METHODOLOGY
Among patients attending the ENT OPD in KMC and GRH, 50 patients of age between 18 to 60 yrs who are clinically assessed for CSOM were chosen for study.
Assessment is based on the following criteria:
1.History of persistent otorrhea and hard of hearing.
Post Auricular Incision
Tympanomeatal Flap Elevation
Cortical Mastoidectomy
Post Operative Tympanic Membrane
2.Otoscopic evidence of chronic suppurative otitis media with central perforation.
3.Examination on table with Microscope.
4.Audiological evidence of conductive hearing loss.
For all patients Diagnostic nasal endoscopy was done and CT scan paranasal sinuses were taken for patients with sinusitis. If septic foci found patients were taken up for endoscopic sinus surgery and disease cleared. Allergic symptoms were treated with steroid nasal spray and antihistamines.
Culture and sensitivity of ear discharge was done and treated with appropriate antibiotics. Patients were given medical treatment for 3-4 weeks, and once the evidence of response obtained patients were randomly selected by an unrelated personnel and put into either group I i.e.Cortical mastoidectomy with myringoplasty or group II i.e.
Myringoplasty alone.
The selected cases were made to undergo appropriate investigations. Routine blood investigations like Hemoglobin,total and differential count, bleeding and clotting time, chest x-ray, ECG and urine investigations were done for all patients.
X-ray both mastoids lateral oblique view were taken for all cases to assess the pneumatisation pattern of mastoid and to know the status of tegmen and sinus plate. Pure tone audiogram was done in sound proof room using Maico ma 52 clinical diagnostic two channel audiometer.
Informed consent was obtained from each patient after counseling them and their relatives regarding the nature of disease and surgery. Outcome and all possible complications were also explained.
All patients were admitted one day prior to the surgery.18 cases in group I and 20 cases in group II cases were operated were done under general anesthesia. And 7 cases from group I and 5 cases from group II were taken up under local anesthesia. Temporalis fascia graft was harvested in all cases. All cases were approached through the postaural route because of its definite advantage over endural route. Less skills necessary, more exposure is attained and complications such as perichondritis never occur. An area comprising 5 cm. above the upper border of pinna and 5 cm. behind pinna was shaved off hair.
Preparation of grafts:
For taking temporalis fascia graft, either a separate incision in the temporal region or an extension of the classical post-aural incision to temporal region was done. Through this incision of about 2 inches length, the temporalis fascia was exposed after dissecting and retracting superficial tissues. About 3 cm circular area of temporalis fascia was cleaned off the loose connective tissues. After injecting about 2 to 3 ml.
of 1% xylocaine between fascia and muscle underneath, an adequate size fascia was cut using a No.15 blade and dissected off, from the underlying muscle using periosteal elevator and non-toothed thumb forceps. Wound was closed in layers after attaining haemostasis.
Procedure for cortical mastoidectomy:
After harvesting Temporalis fascia graft , Mastoid cortex was exposed through a Modified William Wilde incision. Edges of the perforation freshened, tympanomeatal flap elevated and middle ear inspected for any disease. If present it was removed, and ossicular status was checked.
Mastoid antrum was entered after identifying bony landmarks.
Mastoidectomy was done and aditus block, if present were removed.
After confirming adequate drainage has been obtained, Graft was placed by underlay technique and tympanomeatal flap repositioned. Ear canal
was packed with medicated absorbable gelatin sponge and ribbon gauze and mastoid compression bandage applied.
Procedure for myringoplasty:
Same as above procedure except for entering the antrum and clearing disease from middle ear.
Postoperative intravenous antibiotics were given for 7 days and oral antibiotics continued for 2 weeks. Post aural sutures were removed on 8th post operative day.
All patients were followed up weekly for first one month, biweekly for next 3 months and once month till 6 months. Post op Pure Tone Audiogram was done on first, third and sixth months and duly recorded.
During every follow up cases were evaluated for persistence of discharge, take up of graft, subjective and objective audiological improvement and other complications.
OBSERVATIONS
Age and gender distribution:
S no Age Group I(n=25) Group II(n=25) Male Female Male Female 1 18-30 6 (24%) 7(28%) 7(28%) 7(28%) 2 31-40 4(16%) 4(16%) 5(20%) 4(16%) 3 41-60 3(12%) 1(4%) 2(8%) 0(0%)
13(52%) 12(48%) 14(56%) 11(44%)
In our study total number of patients were fifty. Out of which 25 patients were in cortical mastoidectomy with tympanoplasty group(Group I),of which 13 were males and 12 were females. The other 25 patients belonged to myringoplasty only (Group II) 14 males and 11 females in that group. Maximum number of patients belonged to 18 to 30 years range. Youngest patient was 18 years and oldest patient was 56 years.
Socioeconomic status:
S. No Status Group I(n=25) Group II(n=25) Male Female Male Female 1 Low 12(48%) 11(44%) 11(44%) 10(40%) 2 Mid 1(4%) 1(4%) 3(12%) 1(4%) 3 High 0(0%) 0(0%) 0(0%) 0(0%)
0 1 2 3 4 5 6 7
Male Female Male Female Male Female 18-30 years 31-40 years 41-60 years 6
7
4 4
3
1
7 7
5
4
2
0
Frequency
Age and gender distribution Group 1 (n=25) Group 2 (n=25)
The population we cater mostly belongs to low socio economic strata, where in chronic otitis media is more common. The middle and high class population together constituted only 8% and 16% in group 1 and group 2 respectively where as low socioeconomic population was 92% in group 1 and 84% in group2 in our study.
0 2 4 6 8 10 12
Male Female Male Female Male Female
Low Middle High
12
11
1 1
0 0
11
10
3
1
0 0
Frequency
Socio Economic Statistics and Gender distribution
Group 1 (n=25) Group 2 (n=25)
Duration of discharge:
S. No Duration (years) Group I(n=25) Group II(n=25)
1 <5 years 4(16%) 5(20%)
2 5-10years 10(40%) 9(36%)
3 Since childhood 11(44%) 11(44%)
In both groups maximum number of patients had history of otorrhea from childhood(44% each).The number of patients in 5 to 10 years range were 10 in group I and 9 in group II.
0 10 20 30 40 50
<5 years 5-10years Since childhood 16
40
44
20
36
44
Percentage
Duration of discharge (years) Group1 (n=25) Group2 (n=25)
Duration of Hard of Hearing:
S. No Duration (years) Group I(n=22) Group II(n=21)
1 <1 year 6(27.3%) 5(23.8%)
2 1-5years 10(45.5%) 7(33.3%)
3 5-10yrs 6(27.3%) 9(42.9%)
Though maximum number of patients with ear discharge belonged to since childhood period, hard of hearing was maximum in the 1 to 5 years range.
Laterality of the disease:
S. No Laterality Group I(n=25) Group II(n=25)
1 Bilateral 11(44%) 9(36%)
2 Right ear alone 9(36%) 8(32%) 3 Left ear alone 5(20%) 8(32%)
In group I 11 patients had bilateral disease and 14 patients had unilateral disease of which 9 patients had right ear disease and 5 patients had left ear disease. In Group II 9 patients had bilateral disease and 16 patients had unilateral disease.
Size of perforation:
S. No Size of perforation Group I(n=25) Group II(n=25)
1 Small 7(28%) 8(32%)
2 Medium 9(36%) 10(40%)
3 Large 9(36%) 7(28%)
0 10 20 30 40 50
Bilateral Right ear alone Left ear alone 44
36
20 36
32 32
Percentage
Laterality Group1 (n=25) Group2 (n=25)
In group I 36% each had medium to large perforation.Only28% had small size perforation.In group II 40% had medium sized and 32% had small size perforation. Only 28% had largeperforation. Among the cases that failed in group II 2 cases had large perforation.
Status of Middle Ear(ME) Mucosa:
S. No Status of ME mucosa Group I(n=25) Group II(n=25)
1 Normal 13(52%) 12(48%)
2 Congested 7(28%) 8(32%)
3 Polypoidal 5(20%) 5(20%)
In both the groups maximum patients had normal mucosa. 20% of patients in either group had polypoidal middle ear mucosa. 28% in group I and 32% in group II had congested mucosa. This is the recorded finding of the patient at their first visit. All patients with abnormal mucosa was treated with culture sensitive local antibiotics. A few who were refractory to outpatient treatment was admitted and given intravenous antibiotics. Treatment was given for a period of 3-4 weeks and after obtaining evidence of response patients were taken up for surgery.
